Clinical Issues in Substance Abuse Treatment With Transgender Individuals

Ratner (1993) points out that treating substance-abusing gay men and lesbians means being aware of their unique problems in order for treatment to be effective. The same can be said for transgender substance abusers. Aspects such as societal and internalized transphobia, violence, discrimination, family issues, isolation, lack of education and job opportunities, access to health care, and low self-esteem, among others, need to be addressed in the treatment environment.

Like all potential clients, transgender substance abusers bring a variety of experiences with substances and readiness to change into the treatment setting. Many transgender people have had one or more negative experiences with institutions, including those that provide health care. They may be unusually distrustful of professionals and treatment recommendations. It is vital to remember that these clients, like all clients, need to be met with sensitivity and respect. Clients should be allowed to self-identify and cannot be judged on the basis of their self-identification.

Conducting a comprehensive bio-psychosocial assessment is very important with transgender individuals. Because all assessments shouldbe designed to elicit the full spectrum of relevant information, it is appropriate to ask each client about his or her sexuality, gender identity, and comfort with his or her sex role. It is vital that counselors avoid the common pitfall of focusing on gender issues as the assumed root cause of the addiction problem. When inquiring about the client’s substance use, counselors need to recognize that substance abuse among transgender people can involve multiple patterns of use, misuse, and abuse; that multiple causal variables combine to produce problems; that treatment should be multimodal to correspond to a client’s particular pattern of abuse; and that treatment outcomes vary from individual to individual (Lewis, Dana & Gregory, 1994). Using this broader view, treatment providers can better understand substance abuse problems with transgender people and diagnose and treat them less dogmatically.

Another point is to recognize that transgender people will bring unique issues into the treatment setting. Some of these issues are obvious, like the lack of family and social supports, isolation, low self-esteem, internalized transphobia, etc., but other issues may not be as obvious. Getting these other issues to surface will require an environment that is sensitive and nonjudgmental. This is especially true when attempting to access inpatient medical or inpatient substance abuse rehabilitation services. Clinicians working with transgender people must have a solid and reliable referral network that they are sure can work with transgender clients in the most sensitive manner possible.

Hormone therapy is an often overlooked clinical issue. Many transgender clients will be on estrogen or testosterone therapies upon entering treatment. Clients should not be asked to choose between hormones and substance abuse treatment. Hormone treatment is a standard and accepted medical treatment for transsexuals, and clients should be supported by providers to maintain regular, legally prescribed hormonal treatment under proper medical care without interruption. It is important that both the clinician and the client understand that both estrogen and testosterone therapies can affect mood, especially when taken improperly. There may be additional risks associated with using and/or self-injecting “street” or “black market” hormones. This is a particular concern for transgender men, since testosterone must be injected. Obtaining or using needles may be relapse triggers for clients in early recovery.

The issues and difficulties with inpatient treatment and the placement of preoperative or non-operative transsexuals extend to housing and homeless shelters. The housing issues that face homeless transgender people are a major issue in recovery. Very often the stigma and discrimination that transgender individuals face in the homeless services system are their justification for reengaging with individuals who are not a positive recovery influence and increase their relapse potential.

Additional relapse triggers or significant clinical issues for transgender clients might include (1) the inability to find, engage in, or maintain meaningful or gainful employment simply because they are transgender; (2) a lack of formal education or job skills because they were forced to leave school or home prior to obtaining those basic skills; (3) being HIV positive, asymptomatic, and healthy and desiring sex reassignment surgery but having trouble obtaining it due to their HIV status; (4) the overall lack of accepting social supports who are sober and positive role models; (5)issues of sexual orientation as well as gender identity; and (6) stress resulting from their invisibility and the dissonance caused by “passing” (blending into the mainstream).

An additional clinical issue is that many substance abuse treatment providers feel they cannot identify or empathize with transgender people, thereby creating a barrier in developing a therapeutic relationship. It is worth noting that many of the issues faced by transgender men and women may be those faced by non-transgender men and women. Many transgender women have sexual abuse histories, have co-occurring eating disorders or depression, or have never been in a sober relationship or experienced sober sex. Due to their particular invisibility, less is known about transgender men, but clinicians might expect to see a variety of men’s issues in such clients. To provide the best care possible, it is the responsibility of clinicians to enhance their knowledge of substance abuse issues along with their understanding of any issues that will help clinicians understand the treatment needs of their clients.